1) An escape fire (a fire started to escape a bigger fire) is a significant metaphor used throughout the film. It implies an “improvised, effective solution” to an issue failed by traditional approaches. In the context of your film, where do you see escape fires first taking hold if change is to occur: with patient choice, with medical practice, another avenue, or a systemic movement towards change?

For the first year and a half of making this film the working title was A Tale of Two Systems, which is really one of the worst film titles of all time. During the making of the film someone sent us an essay called “Escape Fire: Lessons for the Future of the Health Care System,” by Dr. Don Berwick based on a speech that he gave about 10 years earlier where he draws a metaphor between a forest fire in 1949 and our burning healthcare system. In the essay Dr. Berwick is essentially saying that there are solutions right in front of us, but because we’re so stuck in the status quo, we can’t recognize them.

And so I think, in the context of the film, there are many escape fires that we’ve pointed out but first and foremost we have a disease care system not a health care system; a system that is oriented and profits from sickness, not from keeping people healthy. So we as a society need to find ways to create a system of health; a system that incentivizes people to be healthier; a system that incentivizes doctors and team-based systems to provide care before disease actually takes place as opposed to only treating disease after it occurs. Seventy-five percent of healthcare costs in America are diseases that are largely preventable.

This is really a multifactorial problem, and as such really requires multifactorial solutions. But change is happening. We are seeing change happening all across the county, positive change. As we’ve been able to meet people all across the country from screening the film hundreds of times we’ve found change is really happening at the local level. And as this change is occurring community by community, hospital by hospital, hopefully it will become the norm, not the exception.

2) It is clear that Steven Burd, the CEO of Safeway, is a pioneer in reducing employee health care costs and is highlighted in Escape Fire for his efforts in influencing his workforce to create healthier behaviors through extrinsic means. What’s your opinion on the role of this economic innovation in motivating people to engage in healthier behavior?

In 2005, Safeway had a billion dollar health care bill and Steven Burd realized that it was clearly not sustainable. So, he incentivized his employees to eat healthier, lower their cholesterol, lower their weight, stop smoking and through that he not only improved the health of his employees, but he improved the bottom line for his company. I think providing positive incentives holds great promise in creating a healthier society. There are many, many large corporations, and small corporations as well, that are doing (or trying to do) what Safeway has successfully done.

I really believe that the private sector has a big role to play in terms of helping to solve our healthcare crisis. Roughly 178 million people get their healthcare through their employer, so if more solutions can come out of the private sector we will all be better off. The key is not to blame the individual–it’s my belief these incentives should not be positioned as penalties. In my opinion, the key is to figure out how to incentivize people to stay healthy. And with Safeway, it’s important to acknowledge that the story is not just about incentives; Mr. Burd changed the company’s culture. He changed how his employees thought about health and healthcare and provided opportunities for them to make changes–that’s why he was so successful.

3) There are so many facets to the ongoing health care crisis in America. If you were able to create Escape Fire Part II with unlimited resources and access what would be the next chapter of your exploration of this topic?

I think if we were going to do a part two we would start looking at the ramifications of The Patient Protection and Affordable Care Act. There are many aspects of the Act that people really don’t quite understand and that are going to play out over the next couple of years. One key element are Accountable Care Organizations that are moving us away from a “fee for service” model that currently compensates and incentivizes quantity over quality. It would be interesting to examine whether paying for outcomes – i.e. paying for quality – is a better way of doing things. Also looking at the expansion of electronic health records and other ways that make the system more efficient are key aspects that we were not able to examine in the original film but are key aspects of this complex story.

4) I found it compelling in Escape Fire that Dr. Martin (a physician whose story is documented in the film) externally struggles with the lack of a crisis counselor during the lunch hour when one of her patients is in need, but internally struggles with the desire to maintain her own autonomy — and practice medicine on her terms — stating, “I’m not interested in getting my productivity up, I’m interested in helping patients.” A quagmire is evident in the balance between accessibility and quality of care. In your exploration of this topic, do you believe it’s possible for the system to have it both ways?

Yes, the problem Dr. Martin faced in the film is only going to get more poignant as time goes on. It is estimated that we will have 30 million more people entering the system with the new healthcare legislation. We already have a shortage of primary health doctors, so the story we see with Dr. Martin where she’s forced to see a revolving door of patients that is going to be an ever-growing problem if we don’t change it.

It is very important to give access to care, but it is also important that doctors are given the ability to spend more time with patients. One solution might be that doctors aren’t the only ones to meet with patients. We can create more team-based systems in healthcare, where nurses and nurse practitioners provide more of the day-to-day, week-to-week, follow-ups freeing up doctor availability. In my opinion, the model in which Dr. Martin was operating where she was forced to see so many patients per hour, that is simply not sustainable. I don’t think anyone would be happy in that model. Patients aren’t happy, doctors aren’t happy, so the model needs to change.

5) You’ve stated that you hope Escape Fire can “catalyze a paradigm shift in how our country views health and healing.” With this aspiration in mind, what does success look like in five years?

The film has now been seen by millions of people and it’s been an enormously gratifying journey from the Sundance Film Festival and other festivals, to playing theaters, iTunes, CNN, etc. I think we’ve really helped raise awareness and helped elevate the issues around healthcare in a digestible and non-political way. One of the reasons we made this film is there’s so much hyperbole and misinformation on the topic of healthcare and we really wanted to try to bring clarity to the situation.

The legacy of the film is the question, “how do we create a highly sustainable healthcare system in the 21st century?” We do that by encouraging individuals and institutions to change. So I hope the film continues to do that, that we continue to raise awareness, that we continue to be used a tool to help propel change.

The momentum is already there. We’ve partnered with the Department of Veterans Affairs, one of the largest healthcare systems in America, and they used the film to launch their Patient Centered Care initiative and humanize various internal issues to their doctors and their leadership. My hope is we can continue to inspire, not just large institutions, but individuals too.